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Infectious diseases and PsychiatryInfectionA child presents with a history of fever and a rash. The rash (lacy in appearance) started on the face and then spread to the rest of the body 1-2 days later (see image) What is the most likely causative organism?A child presents to the GP with a history of fever, malaise, conjunctivitis, coryza and a cough. She has a widespread blanching maculopapular rash associated with fine desquamation which her mother says started behind her ears. The soles and palms are spared. Which of the following are not usually associated with this disease?There is no specific treatment for the condition, but the GP recommends a few things to help relieve the child’s symptoms. Which of the following is not recommended?week of a sore throat. 3 weeks of malaise, fever and headaches and 1 and inguinal lymphadenopathy. His temperature is 37.6°C, pulse rate 84 bpm,lary BP 120/82 mmHg and respiratory rate 12 breaths per minute. Investigations: White cell count 11.2 × 109/L (3.8–10.0) Lymphocytes 5.5 × 109/L (1.1–3.3) ALT 72 IU/L (10–50) AST 45 IU/L (10–40) Alkaline phosphatase 91 IU/L (25–115) Bilirubin 16 µmol/L (<17) What investigations is most likely to confirm the diagnosis ?Which of the following is true regarding the condition pictured?Exanthema Serology = IgM raised in acute infection IgG denote long term infectionExanthema buzz words (all maculopapular rash) • Measles = rash starting behind ears , white spots inside of mouth • Rubella= low grade fever, prominent sub-occipital lymphadenopathy, arthralgia • Parvovirus = slapped cheek • Roseola = child with high fever followedby rash, risk of febrile convulsions • EBV= glandular fever tonsillar inflammation, fatigue lymphadenopathy splenomegaly, monospot initial testExanthema Buzz Words Cont. Parvovirus B19 EBV Erythema nodosum – also in IBD Measles CellulitisA 65-year-old man is on the general surgery ward following a Nissen fundoplication. He receives antibiotics for a surgical wound infection. omeprazole, allopurinolpril, finasteride, tamsulosin, salbutamol inhaler, He develops profuse diarrhoea watery diarrhoea 10-15 times a day with severe painful abdominal cramps and a fever. Stool culture confirms the presence of Clostridium difficile. Which of his regular medications is most likely to be associated with an increased risk developing a Clostridium difficile infection?Which of the following antibiotics is not associated with Clostridium difficile infection in hospital patients?He undergoes severity assessment. He has one severity marker (T>38.5). This is his first episode of C difficile infection. What is the most appropriate management of this patient?Clostridium Difficile • Gram positive rod --> pseudomembranous colitis • Features • Risk factors: Abx use (The 4Cs and PT), PPIs • Diarrhoea,abdo pain • Raised WCC • Diagnosis • Stool sample for C. difficile toxin (CDT) • Management • Isolation to a side room • Abx – oral vancomycinfor 10 days • 2 line: oral fidaxomicin • Life-threatening: oral vancomycin + IV metronidazole The4 Cs + Pip-Taz •Cephalosporins •Ciprofloxacin (quinolones) •Clindamycin •Co-amoxiclav •Piperacillin-tazobactam (azocin)A 35-year-old from Pakistan presents with weight loss, and haemoptysis. His chest X-ray is shown. What is the most likely underlying diagnosis?Which of the following is true regarding treatment of TB? Tuberculosis 1. Isolate patient in a negative • Rifampicin (R) pressure room • Orange bodily fluids, rash, hepatitis 2. 3 x sputum (ZN stain, • Isoniazid (H) routine culture, TB culture) • Peripheral neuropathy 3. Refer to TB team • Pyrazinamide (Z) • Gout, arthralgia • Ethambutol (E) RHZE for 2months + RH • Optic neuritis for 4 months = 6 month RxA 35 year old man returns from a business trip in Ghana. A 3 weeks later he goes to his GP complaining of feeling feverish with a sore throat and a headache for the last few days. On examination he has a temperature of 38.4 and a maculopapular rash on his chest and trunk. Which single disease is it most important to test for in this man?The man tests positive for HIV and is started on ART. pain, fever and productive cough. CXR shows features suggestive of pneumonia.est The patient admits to not taking his medication every day as he should. CD4 count: 300 Which is the most likely organism responsible for this man's LRTI?With regards to complications of HIV, which of the following is true? HIV complications by CD4 count >500: malignancy, pulmonary TB, lymphoma, kaposis sarcoma <500: shingles, oral candidiasis, recurrent bacterial pneumonia, <200: Pneumocystis Jirovecii <150: Toxoplasmosis <100: Cryptococcus <50: CMV (more common non Hiv immunsupression), Mycobacterium Avium Complex (MAC), molluscum contagiosumhave developed a fever and now have a rash over their legs.and confusion. They His temp is 39 and cap refill time is 4s . Emergency transfer to hospital is arranged what is the other drug should given at this time ?A 65 year old woman becomes confused 5 days after an anterior resection for rectal carcinoma. beclomethasone and subcutaneous dalteparin.ed salmeterol and Her temperature is 38.0℃, pulse 100 bpm, blood pressure 88/70 mmHg, respiratory rate 30 breaths per minute, oxygen saturation 98% breathing oxygen 15L/min via a non-rebreath mask. She has inspiratory crackles at the right base. She has abdominal central abdominal tenderness and guarding. She is receiving intravenous fluid resuscitation. Blood cultures have been sent. What is the most appropriate next step? SIRSand Sepsis Systemic Inflammatory Response Sepsis = SIRS + infection Syndrome Severe sepsis = sepsis + T>38°C or <36°C HR >90/min hypotension (systolic<90mmHg) or hypoperfusion of one organ RR>20/min WBC>12,000cell/mm^3, <4000 Septic shock = Severe sepsis associated with hypotension for >1hr despite appropriate fluid resuscitation SepsisSix B lood cultures Take 3 U rine output 1. Blood cultures 2. Lactate F luids 3. Urine output A ntibiotics L actate Give 3 1. Oxygen O xygen 2. Fluids 3. AntibioticsA patient comes in for investigation for a pyrexia of unknown origin. on Ix bilirubin is slightly high and viral serology is sent for. The results are as follows. HBsAg -ve Anti-Hbs -ve IgG anti HbC +ve What disease state does this patient have?Hepatitis Basics • A- travel to India; shell fish , vomiting , jaundice very high ALT • B- Symptomatic acutely but commonly becomes chronic and asymptomatic, BBV and Sexually transmitted • C- Chronic , Cirrhosis , Cancer BBV and Sexually transmitted, HCV RNA test • D- only coinfection B suspect if acute worsening of B • E- can be carried in pork , faeco-oral spread, GI symptoms + jaundiceHepatitis B Serology • HBsAg develops in acute infections or active reactivations (HBsAg +ve greater than 6 months suggests chronic infection) • Anti HbC shows high infectivity • Anti-HBs shows immunity • IgG anti HbC with -ve HbsAg and HbS is suggestive of chronic infectionInfectious diarrhoea buzzwords • Very shortly after eating : S. aureus • Reheated rice : Bacilluscereus • Post BBQ diarrhoea : Camphylobacterjejuni • Nursing home outbreak: C. diff or norovirus (if vomiting as well) • Vets = Cryptosporiduim • Chronic foul smelling fatty stools with abdominal distention, associated with travel= GiardiaOther basic bacteriology • Pneumonia: most common= Strep pneumoniae (gram +ve cocci) • Post influenza staph aureus • UTI= E. coli =80% (gram-ve baccili = coliform) • Joint infections + Impetigo = gram +ve cocci (S. aureus most common) • Gas gangrene= Clostridiumperfringens (gram +ve rod) • Gram –ve cocci= N.menigitis , gonorrhoea and morexallPsychiatry Case 1 Mark, 32, presents to his GP with a 2/12 Hx of low mood. He is unable to say what he enjoys doing, he no longer plays football with work friends or golf at weekends all of which he used to do regularly. He feels he has no energy and constantly feels tired, which he puts down to poor sleep. He has come to the GP now because he fears his relationship is breaking down, mainly due to his loss of interest in sex which is causing significant strain.Q: In line with ICD-10 criteria, which two of the following are considered associated symptoms rather than core symptoms of depression?Mark has a 2/12 Hx of low mood. He is unable to say what he enjoys doing, he no longer plays football with work friends or golf at weekends all of which he used to do regularly. He feels he has no energy and constantly feels tired, which he puts down to poor sleep. He has come to the GP now because he fears his relationship is breaking down, mainly due to his loss of interest in sex which is causing significant strain. Q: Assuming Mark has no additional symptoms, what would his Dx be under ICD-10 criteria ?The GP refers Mark for CBT but due to the long waiting list she also decides to prescribe Mark an antidepressant. In Mark’s drug history she notes he is prescribed amiodarone as "pill-in-pocket" therapy for paroxysmal AF. Q: Which of the following treatments are completely contraindicated?Q: Given his main concerns, what would be the single most appropriate antidepressant to prescribe in the first instance? ICD-10Criteria Core Symptoms Associated Symptoms • Persistent sadness/low mood • Disturbed sleep • Anhedonia • Poor concentration, • Fatigue/low energy indecisiveness • Low self-esteem • Appetite change (↑ or ↓) • Suicidal thoughts • Agitation, slowing of movements • Guilt/self-blame Antidepressants • Prescribed for: NICE guidelines: • Depression • Antidepressants are NOT • Anxiety first line treatment for mild • Panic disorder depression • Antidepressants • OCD recommended in moderate- • PTSD severe depression • Very effective • weeks of treatmentt is highest in first 2 PrescribingAntidepressants 1) First-line: Fluoxetine/Sertraline (SSRI) If third drug fails think about: 2) If fails  Citalopram(SSRI) • Augmentation e.g. Lithium • Older drugs e.g. MAOI 3) No response  Switch in class • ECT • Venlafaxine (SNRI) • Mirtazapine (NaSSA) • Amitriptyline (TCA) SideEffects Q. Which depression treatments are associated with: A) GI upset, sexual dysfunction, hyponatraemia in older people - SSRIs B) Weight gain, sedation - Mirtazapine, TCAs C) High risk in overdose - TCAs D) Hypertensive crisis - MAO inhibitors E) Confusion, myalgia - ECT Case 2 Shelly, 38, presents to mental health services followingreferral from the GP . Her husband recounts she has been behaving inappropriately e.g. jumping on his bosses back when he was round for dinner. This is completely out of character. Additionally, Shelly has embarked on “new projects”which she believes will help end world hunger, none of which she has been able to complete. These task have distractedher from picking her children up from school on multiple occasions. She barely sleeps but remains in an elated mood with high energy. When her husband tries to talk to her about it she gets very irritable and unkind.Q: Based on Shelly’s symptoms, what is your initial diagnosis?You speak with Shelly. During the interview you notice her speech is very pressured and at times you struggle to follow her sentences. Not only is Shelly speaking quickly, but she takes a long time to answer your question fully and often includes lots of unnecessary stories and information. Q: Which of the following most accurately describes Shelly’s speech?Q: Assuming Shelly has bipolar disorder, which of the following treatments would be most appropriate to start at this current point?Q: Which of the following symptoms is indicative of mania rather than hypomania?Q: Which of the following is NOT a side effect of lithium therapy?Shelly is started on lamotrigine for prophylaxis of depressive episodes. She develops a maculopapular rash, concentric circles of erythematous and pale skin on her hands, and has a blister on her lip. Q. What is the best management option? UnipolarDepressionvs Bipolar Disorder Unipolar Bipolar •13% pop. Lifetime risk •1-2% pop. Lifetime risk •2:1 F:M risk •F = M risk •Teens and 60+ •Mid 20s •10% mortality •10-15% mortality Overlapof Mood Disorder Syndromes • Depression – Bipolar disorder • Late mania presentation • Undetected mania • Mania presentingas irritability • Depression – Schizophrenia • Depression may occur during or preceding schizophrenia • Depressed patientscan have psychotic episodes • Depression – Anxiety • ¾ depressed people will experience anxiety Definitionof BipolarDisorder • At least two episodes of mood change • At least one episode needs to have been hypomania/mania/mixed affective state MedicalTherapyfor Bipolar Disorder Acute Hypomania/Mania Long Term Management 1. Stop offendingdrugs (e.g. antidepressants),optimise 1. Discussion with patient: existing therapy staying on drug that worked in 2. Start antipsychotic acute episode vs. switch to lithium 3. Addon lithium st Acute Bipolar Depression 2. Lithium 1 line 1. Optimise existing therapy 3. Anticonvulsant mood 2. SSRI (e.g. fluoxetine) + stabilisers e.g. lamotrigine, antipsychoticcombination valproate or antipsychotics AdverseEffects of Lithium • Low thyroid • Heart (ebstein’s, ECG changes similar to hyperkalaemia) • Insipidus • Unwanted Movements (tremors and other neuro e.g. ataxia, confusion) • LiTHIUM Case 3 A 60-year old “frequent attender” has presented to A+E after a fall. When looking at his notes you notice that he has had a recent admission for acute pancreatitis and drinks 100+ units of alcohol per week. On further examination, you notice that he has several features suggestive of Wernicke’s encephalopathy.Q: Which of the following is NOT a feature of Wernicke’s encephalopathy?The patient is commenced on IV pabrinex for thiamine replacement. Q: Which further medication should be prescribed for this patient to prevent complications from alcohol withdrawal while in hospital?Q: Following alcohol withdrawal when is the peak incidence of delirium tremens?Following successful alcohol detoxification, he is started on maintenance therapy. Q: Which of the following drugs is used reduce cravings in alcohol dependence?Q: Which of the following is NOT an official part of the ICD-10 criteria for substance dependence?Alcohol • Detoxification – Benzodiazepines • Thiamine (Vitamin B1) • Relapse prevention – Disulfiram, Acamprosate, Naltrexone Case 4 A 75-year-old man comes to clinic with his daughter. His family are concerned about his short-termmemory problems. Over the past 8 months he has been regularly forgetting things, has episodes of dizziness,and needs to be reminded to take his regular medication. He is behind on his energy bills which he forgets to pay. He has a PMHx of T2DM, HTN, COPD and suffered a small stroke 12 months ago. He continues to smoke. On an MMSE he scores 21/30 with an abnormal clock drawing.Q: What is the most likely cause of this man's cognitive decline?Q: Which of the following is protective against dementia?Q: Which of the following drugs is NOT an acetylcholinesterase inhibitor?Q: Which of the following drugs is the first-line recommended treatment for vascular dementia?Q: Which of the following side effects is unlikely to be seen with Donepezil?her mother is progressively finding it difficult to remember words for commont objects, describing many things as "thingamabob". She is still independent around the house and is otherwise having no issues remembering to do things such as chores or appointments. On examination, you find that on the MOCA she scores particularly poorly on the naming and abstraction sections. What is the most likely diagnosis? Typesof Dementia • >65s • Age is most important risk factor • F>M Alzheimer’ s • Gradual progression = • Amyloid plaques + Dementia neurofibrillary tangles Typesof Dementia • Age is biggest risk factor • Fluctuating cognition Dementia • Visual hallucinations = with Lewy • REM sleep disorder • Parkinsonism Bodies Typesof Dementia Either •dysfunction, apathy,utive Frontotemporal behavioural changes (BvFTD) = Dementia • Language deficits – conduction (primary, or progressive aphasia) th Source: The Maudsley Prescribing Guidelines in Psychiatry (12 Edition) Case 5 A 14-year-old girl, Sarah, is at clinic with her mother. Sarah is struggling at school. She is significantly distressed about her ability to do well in exams and have a successful future, and is plagued by insecurities and worries about her appearance. These feeling are present more days than not. She requires constantreassurancefrom her parents and teachers, and has started having trouble sleeping and concentrating. It is affecting her social life and she no longer hangs out with her friends like she used to.Q: What is the most likely underlying emotional disorder from which Sarah is suffering?Q: Which of the following is most likely to present only after the age of 10?Sarah’s mother is very concerned that Sarah’s anxiety could develop into depression. Q: Which of the following is not indicated in the management of depressionin young people?Sarah’s mother is very concerned that Sarah’s anxiety could develop into depression. Q: Which of the following is not indicated in the management of depression in young people? A) CBT NICE: do not offer antidepressant B) Paroxetine medication to a child or young C) Fluoxetine person with moderate to severe D) Supportive therapy E) Guided self-help depression except in combination with a concurrent psychological therapyGood Luck!